Hospice enrollment

Hospice care is a specialized type of healthcare focused on providing comfort, dignity, and quality of life to individuals with a terminal illness. Unlike curative treatment, hospice care does not aim to cure the underlying disease — instead, it manages pain and symptoms while addressing emotional, spiritual, and practical needs of both the patient and their family.

56 steps across 12 sections

1. Recognize the Need

  • The doctor says "there is nothing more we can do to treat the disease"
  • Frequent hospitalizations for the same condition (2+ in the past 6 months)
  • Significant functional decline despite treatment
  • The patient expresses a desire to focus on comfort rather than aggressive treatment
  • Family members or caregivers are becoming overwhelmed

2. Get a Referral (or Self-Refer)

  • Physician referral: Most patients enter hospice when their physician refers them, often after a hospitalization or when curative options are exhausted
  • Self-referral: Patients or family members can contact a hospice provider directly — you do not need a doctor's referral to inquire or request an evaluation
  • Hospital discharge planners and social workers can also initiate hospice referrals

3. Choose a Hospice Provider

  • Research hospice providers in your area (see "Choosing a Hospice Provider" section below)
  • You have the right to choose any Medicare-certified hospice provider
  • Ask questions about services, staffing, availability, and philosophy of care

4. Initial Assessment

  • The hospice team conducts a comprehensive evaluation, including:
  • Review of medical records and history
  • Complete physical examination
  • Assessment of psychosocial, emotional, and spiritual needs (for patient and family)
  • Home safety evaluation (if receiving care at home)
  • Discussion of goals of care and patient preferences

5. Physician Certification

  • Two physicians must certify the terminal prognosis (6 months or less):
  • The patient's attending physician
  • The hospice medical director
  • This certification must occur before hospice services begin under Medicare

6. Sign the Election Statement

  • The patient (or authorized representative) signs a hospice election form
  • This statement indicates the patient understands they are choosing comfort care
  • It specifies the effective date of hospice care and the hospice provider chosen
  • The patient acknowledges that they are waiving Medicare coverage for curative treatment of their terminal condition

7. Develop the Plan of Care

  • The interdisciplinary hospice team develops a personalized care plan
  • The plan covers: medication management, equipment needs, visit schedules, caregiver training, spiritual care preferences, and emergency protocols
  • The plan is reviewed and updated regularly based on the patient's changing needs

8. Core Requirements

  • Terminal prognosis: Two physicians (the patient's attending physician and the hospice medical director) must certify that the patient has a life expectancy of six months or less, assuming the illne...
  • Comfort care election: The patient (or their healthcare proxy) must choose to focus on comfort care rather than curative treatment for their terminal illness
  • Election statement: The patient must sign a hospice election statement, formally choosing hospice care

9. Medical Indicators of Eligibility

  • Functional decline: Increasing dependence on others for Activities of Daily Living (ADLs) such as bathing, dressing, eating, transferring, and toileting
  • Palliative Performance Scale (PPS): Rating of 50-60% or below
  • Unintentional weight loss: More than 10% body weight loss over 4-6 months
  • Increasing weakness and fatigue that limits daily activities
  • Declining cognitive abilities (confusion, disorientation)
  • Recurrent infections despite appropriate treatment
  • Frequent hospitalizations or ER visits for the same condition

10. What It Covers

  • Physician services from the hospice medical director and other hospice physicians
  • Nursing care (registered nurses and licensed practical nurses)
  • Home health aide and homemaker services
  • Medical social worker services
  • Counseling (dietary, spiritual/pastoral, and bereavement counseling for family)
  • Physical therapy, occupational therapy, and speech-language pathology (for symptom management)
  • Medications for pain relief and symptom management related to the terminal diagnosis
  • Durable medical equipment (DME): Hospital beds, wheelchairs, walkers, oxygen equipment, commodes
  • Medical supplies: Bandages, catheters, gloves
  • Short-term inpatient care for pain and symptom management that cannot be handled at home

11. Out-of-Pocket Costs Under Medicare

  • Most hospice services: $0
  • Prescription drugs (outpatient, for symptom management): Copayment of up to $5 per prescription
  • Respite care: Daily coinsurance of 5% of the Medicare-approved amount (cannot exceed the inpatient hospital deductible for the year)

12. What Is NOT Covered

  • Treatments intended to cure the terminal illness
  • Prescription drugs intended to cure (rather than manage symptoms of) the illness
  • Care from a provider not arranged by the hospice team
  • Room and board (if the patient is in a nursing home, the patient or Medicaid may still pay for room and board separately)
  • Emergency room visits or hospitalizations not arranged by the hospice team

Common Mistakes

  • Waiting too long to enroll
  • Thinking hospice means "giving up"
  • Not knowing you can self-refer
  • Assuming hospice is only for the last few days
  • Believing hospice means no more medical care

Pro Tips

  • Ask about hospice early
  • Interview multiple hospice providers
  • Understand the benefit periods
  • Use respite care
  • Request a hospice information visit with no obligation

Sources

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